Tone as a Health Concept: An Analysis

This section is compiled by Frank M. Painter, D.C.
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FROM:   Complement Ther Clin Pract. 2017 (Nov); 29: 27–34 ~ FULL TEXT


Donald McDowall, Elizabeth Emmanuel, Sandra Grace, Marilyn Chaseling

School of Health and Human Sciences,
Gold Coast, Southern Cross University,
Lismore, NSW, Australia

STUDY DESIGN:   Concept analysis.

INTRODUCTION:   This paper is a report on the analysis of the concept of tone in chiropractic.

PURPOSE:   The purpose of this paper is to clarify the concept of tone as originally understood by Daniel David Palmer from 1895 to 1914 and to monitor its evolution over time.

METHODS:   Data was sourced from Palmer's original work, published between 1895 and 1914. A literature search from 1980 to 2016 was also performed on the online databases CINHAL, PubMed and Scopus with key terms including 'tone', 'chiropractic', 'Palmer', 'vitalism', 'health', 'homeostasis', 'holism' and 'wellness'. Finally hand-searches were conducted through chiropractic books and professional literature from 1906 to 1980 for any references to 'tone'. Rodgers' evolutionary method of analysis was used to categorise the data in relation to the surrogates, attributes, references, antecedents and consequences of tone.

RESULTS:   A total of 49 references were found: five from publications by Palmer; three from the database searches, and; the remaining 41 from professional books, trade journals and websites.

MAJOR CONCLUSIONS:   There is no clear interpretation of tone in the contemporary chiropractic literature. Tone is closely aligned with functional neurology and can be understood as an interface between the metaphysical and the biomedical. Using the concept of tone as a foundation for practice could strengthen the identity of the chiropractic profession.

KEYWORDS:   Tone, Chiropractic, Daniel David Palmer, Homeostasis, Wellness, Rodgers' evolutionary concept analysis

From the Full-Text Article:


Tone has been described as the passive neurological condition of strength found in all body tissues. [30] For this reason, gymnasts quest for it, body builders exhibit it and personal health requires it. In the health discipline of chiropractic, tone is a foundational principle for practice. [36] Despite this, tone, and its relevance to contemporary practice, is not well understood. [24, 57, 60] A comprehensive understanding of tone may help explain the schism that has emerged in contemporary chiropractic practice between reductionism and holism. [22]


Since antiquity, ‘tone’ has had multiple meanings that have led to confusion and controversy about its meaning. [30] Tone evolved from the ancient Greek root word ‘tonus’ to describe the breath of life that inhabits the human body. [40] This meaning extended into the realm of metaphysical constructs that were difficult to research and validate with scientific methods. [13, 40] Donahue [7] discussed the two disciplines of Greek healing located at Cnidus and Kos in Asia Minor and compared them to modern chiropractic concepts. He explained that the Cnidian concept is similar to the modern medical theory of reductionism, or reducing the function of humans and nature into parts. [4] The Koan perspective is a holistic study of health and disease, similar to the chiropractic concept of tone. [7] The Koans regarded disease as a disruption of tone or functional unity, leaving the whole person out of balance with nature. They believed in the body's natural ability to heal itself. This ability has been referred to by Hippocrates as ‘vis medicatrix naturae', a Latin term for his self-healing philosophy. [36]

Both perspectives of reductionism and holism have continued to serve humanity over time. Around 200AD, Galen, the Greek physician, during his service to the Roman empire, successfully negotiated a middle ground of drawing from both perspectives. [41] Marcellus, a Roman historian, circa 410 AD, described choices for * Corresponding author. healthcare in Roman medicine as including both these healing perspectives. [41] Galen's work continued to refine and use Greek and Roman medicine in medieval times until the German-Swiss physician, Paracelsus, in the 16th century, reformed medicine from the superstitions of curses and devils to metaphysical arguments seeking cause and cure. It was a patient-centred approach to healthcare that supported a holistic foundation for the concept of tone. During the 16th century the Flemish/Netherlandish anatomist and physician, Versalius, and the French barber surgeon, Pare, used metaphysical reasoning to expand on Paracelsus' ideas of cause and cure, thereby further developing this holistic foundation and beginning the transition to more innovative methods of healthcare evidenced by their work continuing to be published in the 17th and 18th centuries. [51] During the 19th century, the scientific method of investigation was consolidated. [9] This brought great strides in the basic sciences of physics, chemistry, anatomy and biology, relegating tone from the spiritual metaphysical overtones of tonus to an expression of physiological health. [49]

The word ‘tone’ was first used by Daniel David Palmer (D D Palmer), the founder of chiropractic, in the late 1890s to explain health. [34] Palmer's work on tone continued for a period of almost 20 years. [36, 38] During this time, he observed that many personal health issues failed to respond to the healthcare provided. [36] This failure to respond, he argued, was due to a loss of tone in an organ or body system which, when restored or recovered, would build health and empower a person to reach their ‘destiny’. Palmer used the analogy of musical tone to describe a cause-and-effect model of health and disease for chiropractic, which was at odds with causeand- effect models of other health professionals. [12] Since then, the profession has evolved and basic concepts such as tone are being questioned. [47] The aim of this paper is to clarify the concept of tone as originally understood by Palmer and to monitor its evolution over time.


Concept analysis is well established in the health sciences as a methodology to examine concepts. Of the many methods of concept analysis, Rodgers [43] method has been chosen for this analysis as it is systematic, with clear-cut phases. Also, it allows for the clarification, description and explanation of a concept by analysing how it is used within the discipline and in other healthrelated areas. [52] Rodgers described a ‘concept’ as a “cluster of attributes”, and ‘analysis’ as the “breaking apart of a thing to identify its constituent components”. [44] She described her method as ‘evolutionary’ for she argued that concepts are not fixed, rather they are continually subject to change over time.

Rodgers [44] method involves six primary activities, many of which can be undertaken simultaneously during the investigation. First a concept of interest is identified, together with any associated expressions including ‘surrogate’ terms. Care must be taken that any ‘surrogate’ terms are indeed terms that are used interchangeably with the concept, and are not really a related concept. The second activity is to select an appropriate ‘realm’ (setting and sample)for data collection.

The third and fourth activities, the collection and analysis of the data, involve two components. Here the researcher examines the literature, using an inductive and discovery approach, to identify the ‘attributes’ or ‘real’ definition, or common usage, of a concept as opposed to its ‘nominal’ or dictionary definition. [43, 44] As well, the contextual basis of the concept needs to be explored to “gain an understanding of the situations in which the concept is used, the use of the concepts in those varying situations, and its use by people with potentially diverse perspectives”. [44] Here the ‘reference’ of the datadactual situation in which the concept is useddneeds to be collected to assist with clarifying the scope and application of the concept. Where possible, the ‘antecedent’dor events associated with the concept in the pastdneed to be identified. Similarly, where available, the ‘consequences’dor results of the use of the conceptdneed to be determined. [52] A fifth activity requires the researcher to, if appropriate, identify an exemplar of the concept. The sixth and final activity involves identifying any hypotheses, as well as implications for the future of the chosen concept.

      Data sources

Three sources of data were used to collect data for this concept analysis of tone. First, Palmer's 1896 to 1914 articles, chiropractic books and journals were reviewed and the five most relevant sources were selected. A 1910 document by Gregory, a student of Palmer, was also located. Second, searches were conducted for the period 1980 to 2016 in three main relevant databases (CINAHL, PubMed, MANTIS) using key search terms including ‘tone’ and combinations of the associated wordsd‘chiropractic’, ‘Palmer’, ‘vitalism’, ‘health’, ‘homeostasis’, ‘holism’ and ‘wellness’. Three sources were discovered. Third, additional data were retrieved for the 1980 to 2016 period, primarily from chiropractic sources, although other health disciplines were also searched. A total of 41 sources were located from 1980 to 2016 trade journals, websites, private collections and books.

Data were entered on a spreadsheet with columns headed ‘author,’ ‘year of publication’, ‘database’, ‘discipline’, ‘relevance’, ‘page number’, and ‘words and phrases used’. The reading, data entry and analysis were undertaken by the first author. Further analysis culminated in five main columns titled ‘surrogates’, ‘attributes’, ‘references’, ‘antecedents’ and ‘consequences’. When final agreement was reached, interpretations were accepted. When agreement was unattainable, interpretations were omitted.

Table 1A

Table 1B

The results for this concept analysis of tone, as related to the chiropractic profession, are summarized and tabulated according to Rodger's [43, 44] evolutionary analysis protocols. Table 1 provides a summary of the data. Following the table, the results will be discussed using Rodgers' categories of surrogates, attributes, references, antecedents and consequences.


A ‘surrogate’ is a word or words that are interchangeably with the concept being analysed. [44] This analysis revealed five surrogates. In 1900, Palmer interchanged ‘tone’ with the term ‘inharmony’ which he described as a lack of balance or lack of homeostasis. A decade later, Palmer [36] used ‘neurological tension’ which provided a clearer physiological understanding of tone. More than eight decades later, Donahue [7] was aware of the dilemma of tone being poorly understood. He proposed ‘homeostasis’ as an interchangeable term for a new and better version of tone arguing that homeostasis is an effect of tone, not a definition. Tutashinda [54] simplified the complexity of tone by describing it as ‘balance’. Rosner [46] described tone as an optimum health gateway and recommended a better understanding of the chiropractic emphasis on tone as a function of the nervous system.

      Attributes of tone and references

‘Attributes’ and ‘references’ are closely related: ‘attributes’ are the real definition or the common usage or characteristics of the concept, and the ‘reference’ is the actual situation in which the concept was used. [44] To highlight their inter-relationship they will be discussed together. Rodgers and Knafl [44] maintained that the primary achievement of a concept analysis is the identification of the concept's attributes (or characteristics).

A total of 29 sources described the ‘attributes’ of tone and 10 described their ‘references’. These attributes and references showed little development since their first descriptions in Palmer's early work. Attributes of tone were not clearly described in Palmer's early work. [34, 36, 38] Here, he saw tone as a source of energy that could vary and, when variations did occur, they preceded symptoms. For Palmer, when someone had little or no energy this indicated the absence of tone and was therefore linked to poor health and disease. [36] Normal tone, a constant source of energy, depended on nerve tension within the nerve trunk. The nerve trunk became the optimum location to change that tension, regardless of cause [36] and this became the foundation principle of chiropractic. [53] Causes of tension, according to Palmer, included structural pressure, food and chemical poisons, depression and mental health disorders, and fatigue from lifestyle choices. [36] Palmer expanded his concept of tone in later writings. [36, 38] Ebrall [9], by examining the period between 1895 and 1910, linked neurology and tone across health professions and confirmed that chiropractic understanding of neurologywas well established at that time. Collation of Palmer's work indicated that the concept of tone was similar to the creative expression of music or art. [1]

Donahue [6] argued that tone was in essence a driver for optimum health and its reference was to explain quality of life. In a later paper, Donahue [7] researched the loss of emphasis on tone that had occurred in the chiropractic profession and argued that, while tone was poorly understood, it still had value and could provide an innovative way for researching health and disease outcomes for all interventions. Mootz, Coulter, and Hansen [33] studied the growing public use of chiropractic services and proposed an agenda to integrate chiropractic innovations and concepts into mainstream health care. Of the six recommendations that they made, Mootz, Coulter, and Hansen's determination of the barriers to usage of chiropractic came closest to exploring the impact of the loss of emphasis on tone. These barriers included a lack of familiarity with chiropractic concepts like tone and its value for preventative care. Rosner [47] also identified a loss of emphasis of tone over time. He proposed a need for the inclusion of tone into a modern context of functional or therapeutic use of neurology.

Tone was also seen as a medium bridging the physical (spinal manipulative therapy) with general health and physiological processes that are normally outside the scope of musculoskeletal therapeutics. [10] Eingorn and Muhs' research also proposed tone as a common platform that could be understood by all health professionals. Coulter [5] proposed that this broader perspective of tone would allowmetaphysical models of research such as heuristic and phenomenological studies to be added to the knowledge base of chiropractic.

Griner [17] prioritised the neurological changes in tone from structural to systemic to improved general health. Keating [25] described tone as neurally-mediated health of all cells and tissues of the body. These perspectives were expanded further by others in the discipline. For instance, Carey, Clum, and Dixon [3] described tone as a component of the personality of the profession, whilst Senzon [48] considered tone as a moral ethic of improving public health for the profession and a lens to understanding bio-theology. Thus, tone became a cause-and-effect model for chiropractors. By modifying tone, the argument was that pain, metabolic and organ function could alter. Tonewas seen as a means of preventing disease and promoting health. In their research, Masi and Hannon [30] confirmed tone as a baseline for structural function. They constructed a bio-tensegrity systemas a basis for passive human resting muscle tone using the muscle's intrinsic molecular tension. Loomis [29] argued that a better understanding of tone by chiropractors could be gained from clinical research. Research investigating poor muscle-organ function during ill health was a beginning to strengthen the groundwork for the benefits of tone. Kent [27] considered tensegrity as an example of how the chiropractic concept of tone worked with the nervous system. Hohenschurz- Schmidt, Esteves, and Thomson [21] extended the tensegrity system of mechanical structural tension into the concept of biotensegrity from the structural tension observed in human cells.

Others like Kobesova and Kolar [28] and Jang, Park, Park, Kim, and Sohn [23] described tone as a driver for creativity, emotions and learning. Others [8, 20] considered tone to be a metaphysical element of health. Hill, Ellison, Taylor, et al. [20] provided an example of the research needed for metaphysical interventions like tone. They measured the telomere length in human cells as an effect with spiritual beliefs as an intervention. Findings from this study concluded that the intervention had increased telomere length thus, reducing cell ageing. However, they noted that they did not understand the pathway of the effect. Doufesh et al. [8] saw the application of tone as a bridge between prayer and physical health.


‘Antecedents’ are conditions occurring prior to and leading to the formation of a concept. [43] In the 19th century, tone in human physiology was well understood as the passive normal tension of human tissue. [9, 29] The chiropractic concept of tonewas developed for the purpose of helping people with unresolved health problems. [35, 36] Palmer theorised unresolved health problems as resulting from misunderstanding the causation of disease. [7] Palmer's observations led him to question the infectious causes of disease. He questioned why, when two people have similar lifestyles and circumstances, one gets ill and the other stays healthy. He developed the concept of tone to explain this observation. Senzon [49] asserted that tone was founded on metaphysical beliefs based on a premodern philosophy and departing from the previous Cartesian worldview. Others [32] have agreed with this interpretation, namely that Palmer used underlying spiritual beliefs and intuitive learning to develop the concept of tone, which is a mixture of what is understood today as human health, sociology, and neurology. [9, 30, 42] According to Palmer, focusing on tone could address poor health, pain and disease that was not responding to available health treatments or that resulted in adverse effects like addiction to or poisoning frommedication and complications fromsurgery. Tone, as a concept therefore, provided an explanation for Palmer's understanding of the cause of disease. [34]


‘Consequences’ are the events, situations or phenomena that follow the use of a concept. [43, 44] Palmer [36] formed his concepts into a system of health care with the concept of tone as its foundation principle. He then, in 1897, formed a school in Davenport, Iowa, USA, with tone as a themed curriculum. [27] Further expansion of tone into a religious framework was considered for legal protection [37] but not implemented. [16] Tone as a concept provided a platform for research that could provide an evidence-base for chiropractic. Health problems could be perceived in a broader health context, one that included the metaphysical [2, 55], rather than the narrow illness focus model as seen in medicine. [5, 19, 24, 55] This perspective could be seen as a strength of chiropractic. [56] Recognizing strengths and weaknesses of the concept of tone [58] could: enhance the identity of the chiropractic profession [6, 7, 47]; build personality for the chiropractic profession [15, 61]; be a bridge for interprofessional healthcare development [10, 39, 45]; recognize tone as a unique source for creating new knowledge [11, 47], and; overcome internal professional discipline barriers. [31] Epstein et al. [11] posited that tone could improve general health, immunity and nonmusculoskeletal conditions.

A greater emphasis of tone is possible with the [53] classification of the semantics of chiropractic's concepts as traditional, with medical services positioned as complementary, rather than vice versa, to give tone improved context for the profession. Researching the effects of tone on the telomere length may provide evidence that could inform the understanding of tone. [19]

      Concept analysis of tone: summary
Figure 1

The five components of this concept analysis discussed above are illustrated in Figure 1. Together they show how tonewas perceived by Palmer, developed as a foundation concept for health and disease, and discussed by others both within and outside the profession.


The purpose of this researchwas to clarify the concept of tone as originally understood by Palmer and to monitor its evolution over time.

Our analysis found:

  • five surrogates had been used to describe tone: ‘inharmony’, ‘balance’,’nervous tension’, ‘homeostasis’ and ‘optimum health gateway’. Such surrogates are likely to have caused confusion and misinterpretation.

  • 29 attributes or characteristics of tone and 10 references to the actual situation in which the concept was used. There had been little development of the concept of tone although its emphasis in the chiopractic profession had diminished over time. Attributes included sub-clinical symptoms, neural tension, foundation principle of chiropractic, and the personality of the profession. Tone was also considered a moral ethic for improving public health and, for some authors, tone became a cause-and-effect model for chiropractic.

  • 11 antecedents were identified as leading to the formation of the concept of tone. These included metaphysical beliefs and an understanding of the passive normal tension of human tissue. The concept was in keeping with the understanding of neurology at the time.

  • 25 consequences, the most important of which are the chiropractic system of health care with the concept of tone as its foundation principle; the establishment of chiropractic education institutions; the potential for enhancing the identity of chiropractic, and recognizing tone as a unique source for creating new knowledge.

      Concept of tone in chiropractic defined

The concept of tone in chiropractic defines the human nervous system as a pathway for sources of intelligence to interface with human function improving health, thought and knowledge. [36] Tone can be understood using the analogy of the human body as a musical instrument to illustrate this mechanism of expression. The expression of tone through an instrument's vibration, when used over time and with varying intensity, may need mechanical adjusting to maintain its optimum tone. The skill and inspiration of the artist is compared to the intelligence and music created as the expression of knowledge. Tone affects quality of life, resonating through the human body and nourishing it with health. [32] Thus, the concept of tone leans to the historic concept of tonus, recognised as a value of health over time, understood by Palmer as a pathway for knowledge that can be measured and analysed using human physiological changes, developed as a foundation principle into a system of healthcare and taught as a theme in a unique education system that created graduates for a new health profession. Tone defines functional neurology and is an interface to better understand the relationship of metaphysical and mechanical research. [47] This metaphysical concept of tone has the potential for strengthening the identity of the chiropractic profession.

Exemplar   Rodgers [44] recommended the inclusion of an exemplar as a clear illustration of the characteristics of the concept in a relevant context. A model case of tone may be viewed within the framework of a chiropractic clinic. This clinic provides a service where a chiropractor is available for individual advice, a health evaluation for the presenting complaint, observation of any consequential loss of tone, as well as education for the patient on the concept of tone and its effects and treatment to restore tone.

Denise, a fit 38-year-old information technology executive living in southern Queensland learned about chiropractic over lunch through a surfing colleague. After receiving conservative care for neck pain caused by being dumped in the surf three years earlier, Denise decided to seek an opinion from her friend's chiropractor to explore why she had lost her confidence in surfing and did not feel well after the injury. Characteristics of her health status now included restricted general movement, mental dullness, loss of executive ability, digestive sluggishness and a loss of wellbeing. Denise was having difficulty adapting to both her personal lifestyle and work even though a biopsychosocial health evaluation had classified her as fit and normal for her age. Over the next year, Denise decided to follow a treatment programto restore the loss of tone observed by the chiropractor. As the treatment programprogressed Denise could move better without pain in both lifestyle and work activities. She began to surf again. Positive changes of mental clarity and more decisive thinking at work aswell as improved general wellness were also noticed. Restoring her tone with chiropractic care motivated Denise to maintain this state of health with a schedule of chiropractic ‘tune ups’ as part of her wellness goal.

      Implications for the future of the concept

The concept of tone has expanded from using fingertip palpation for measuring the tone of muscle and detection of abnormal heat from the skin in the foundation days of chiropractic to instruments that measure tissue resistance, heat, nerve function, organ function, metabolic change and pain. New technologies creates opportunities for measuring the cause-and-effect model of tone. Tone could be understood as a passive normal for the human body and thereby enable assessment of the nervous system's expansion and contraction.

Tone may hold value in the context of functional neurology as a medium for the health effects of nutrition, environmental and metaphysical interventions such as religiosity, prayer and meditation. Extending this understanding of restoring and enhancing tone with chiropractic adjustments to multiple healthcare interventions promotes a unique personality/identity of the chiropractic profession.


From the concept of tone defined in this paper the following hypotheses arise:

Tone is a medium for restoring and improving health   Tone is often understood in casual comments such as: “you don't look so good today” when referring to skin tone, or “what happened to you” when referring to slumped posture, or “you look tired” when referring to loss of nerve tone. According to Palmer, using a vertebra as an intervention tool to adjust the nerve roots could restore that nerve tone or improve dysfunction and thereby promote a rapid health recovery from multiple causes ranging from injuries, poisoning and stress. While the main reason for patients to seek chiropractic care was health recovery from illness, patients also seek prevention of disease. This challenged the profession to explain how specific health problems were responding to general changes in tone with effect pathways difficult to define. The concept of tone was understood by Palmer and others in terms of symptom prevention, wellbeing expansion and spiritual expression.

Tone is a pathway for molecular vibration   Tone as a pathway for molecular vibration was poorly understood by early chiropractors. New research confirms that molecular vibration can be expressed through nerves as sound. [14] The quality of tone described as vital energy is understood today as an innate intelligence with research concluding it is necessary for the human systems to communicate. [18] According to Palmer [36]; thought, human intelligence and consciousness are expressed through tone driving creative expression, emotions and learning. The proposal that tone neurally mediates the health of all cells and tissues of the body may still hold value for the teaching of tone.

Figure 2

Tone is an interface for the metaphysical   Tone may be understood as an interface where the quality of intelligence can be expressed. Just as a musical instrument may be tuned (‘toned’) and yet still played poorly, so to can a ‘toned’ body not realise its full potential if a person makes poor lifestyle choices thus creating limitations to the free flow of intuitive knowledge. The tone of the nervous system influences the extent to which that knowledge is integrated into the physical structure. (see Fig. 2).

      Implications for the future of the profession

Tone may hold value in the context of functional neurology as a medium for the health effects of nutrition, environmental and metaphysical interventions such as religiosity, prayer and meditation. Extending this understanding of restoring and enhancing tone with chiropractic adjustments to multiple healthcare interventions promotes a unique personality/identity of the chiropractic profession. This metaphysical concept of tone has generated various contributions to modern healthcare. First, it underpinned a system of healthcare known as chiropractic. Second, it generated schools with a themed curriculum adding to modern medical knowledge. Third, a new profession formed with a documented growth in the medical sciences using 'tone’ as a foundation principle of health. Fourth, the concept of tone generated a new platform for a hybrid healthcare model with a research framework seeking to classify tonal health problems. Fifth, tone could be the true personality, not well understood, that underpins the identity of the chiropractic profession.


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